2025 VDS Membership Registration Form

Name*

First NameMiddle NameLast NameDegree

Practice Address:*

Practice Name

Street Address

CityState / Province

Postal / Zip CodeCountry

Office Manager:

First NameLast Name

Office Manager Email:

example@example.com

Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Phone Number:*

Area CodePhone Number

Cell Phone:

Area CodePhone Number

Are you interested in serving on the Board or a VDS Committee?

YesNoPlease send more information

Membership Categories*

Active Member$205.00

This category includes physicians who are Board certified or Board eligible by the ABD or AOBD and are licensed to practice in the Commonwealth of Virginia or who are in active government service. This category includes practicing dermatopathologists who are Board certified or eligible as dermatopathologists but not Board certified or eligible as dermatologists.

Active Member Promo$155.00

This category is only for new members who join and register for the Annual Meeting. This category includes physicians who are Board certified or Board eligible by the ABD or AOBD and are licensed to practice in the Commonwealth of Virginia or who are in active government service. This category includes practicing dermatopathologists who are Board certified or eligible as dermatopathologists but not Board certified or eligible as dermatologists.

Affiliate Member$205.00

This category includes non-dermatologist physicians or scientists engaged in dermatologic research and/or education.

Group/Practice Membership$510.00

Bundle up to 5 members. Membership is included for up to 5 Active physicians.

Trainee Member$ Free

This category includes physicians participating in residency or fellowship training programs in Virginia approved by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association.

Medical Student$ Free

Total $0.00

Name

First NameMiddle NameLast NameDegree

Name

First NameMiddle NameLast NameDegree

Email

example@example.com

Name

First NameMiddle NameLast NameDegree

Email

example@example.com

Name

First NameMiddle NameLast NameDegree

Email

example@example.com

Name

First NameMiddle NameLast NameDegree

Email

example@example.com

Notes:

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Membership Application / Renewal

Group Membership Information